PCN Patient Care Coordinator Ageing Well Service
| Posting date: | 19 February 2026 |
|---|---|
| Salary: | Not specified |
| Additional salary information: | Negotiable |
| Hours: | Full time |
| Closing date: | 06 March 2026 |
| Location: | Lincoln, LN2 2WJ |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | B0324-26-0002 |
Summary
The Care Coordinator will support the delivery of the Ageing Well service within the Primary Care Network, working proactively with patients living with frailty, long-term conditions and complex health and social needs. Clinical Coordination & Caseload Management Proactively identify and manage a defined caseload of patients within the Ageing Well cohort. Coordinate and organise staff rotas on SystmOne for ANP, Frailty Nurse, Occupational Therapist and Pharmacist clinics. Contact patients via their preferred communication method to invite them into the service and arrange appointments. Support seamless transitions between primary, community and secondary care. Liaise regularly with GPs, ANPs, pharmacists, social prescribers and community teams to ensure coordinated care delivery. Actively participate in multidisciplinary team (MDT) meetings and support preparation and follow-up actions. Personalised Care & Support Planning Holistically bring together all of a persons identified care and support needs and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person following the NHS Comprehensive Care Model. See also YouTube NHS Comprehensive Personalised Care Model Explainer Animation. Conduct home visits for housebound patients where appropriate. Review and update care plans at agreed intervals. Promote shared decision-making conversations. Ensure care plans are communicated to relevant professionals and recorded accurately in clinical systems. Escalate any clinical concerns to supervising clinician. Navigation & Signposting Develop an in-depth understanding of local health, community and voluntary sector services. Support appropriate onward referrals to social prescribing link workers and other services. Help patients navigate the wider health and care system. Identify when additional support or intervention is required and raise concerns promptly. Digital & Data Responsibilities Maintain accurate, contemporaneous documentation within SystmOne. Record activity using appropriate SNOMED/read codes to support reporting and audit. Support data quality improvement within the Ageing Well service. Use digital systems to track patient progress and outcomes. Contribute to monitoring service activity and performance metrics. Governance, Safety & Compliance Adhere to safeguarding policies Adults & Children and escalate concerns appropriately. Follow lone working procedures during home visits. Maintain patient confidentiality and comply with information governance standards. Identify and report risks or incidents in line with PCN policy. Participate in clinical supervision sessions with supervising GP/ANP. Work within the defined scope of the Care Coordinator role and avoid providing clinical advice beyond competence. Participate in the management of patient complaints when requested to do so and participate in the identification of any necessary learning brought about through incidents and near-miss events. Maintain a clean, tidy, effective working area at all times Service Improvement & Development Identify service gaps and provide feedback to improve delivery. Contribute to quality improvement initiatives within the PCN. Support service monitoring through accurate recording of interventions and outcomes. Assist in evaluation of patient experience within the service. Professional Development Participate in regular one-to-one supervision meetings. Engage in mandatory training and ongoing professional development. Take part in annual appraisal and objective setting. Work collaboratively with other Care Coordinators across the PCN. Outcome Expectations The post-holder will contribute to: Increased completion of personalised care plans. Improved frailty identification and coding accuracy. Reduction in avoidable hospital admissions where appropriate. Improved patient experience and continuity of care. Effective MDT coordination and follow-up. In addition to the primary responsibilities, the Patient Care Coordinator has the following wider responsibilities: a. Support the delivery of QOF, incentive schemes, QIPP and other quality or cost effectiveness initiatives a. Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner b. Duties may vary from time to time without changing the general character of the post or the level of responsibility Duties may vary from time to time without changing the general character of the post or the level of responsibility